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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles.

Protection for sex workers needs to include access to contraception and maternity services. Health interventions need to be underpinned by the right political and legal framework.

The review article “Better health for sex workers: which legal model causes least harm?” highlights the importance of sexual and reproductive rights of sex workers in the UK, and the need to prevent sexually transmitted infection and sexual violence.

Legalisation and subsequent regulation of sex work would be likely to have a positive impact upon the sexual and reproductive health of sex workers. Sex workers themselves report that their ability to use condoms improves when they are in a safe environment where they can have alarm systems to help if clients attempt to engage in sex that the sex worker has not agreed to(1). This would currently be prohibited as it would be regarded as ‘brothel keeping’.

However, sex workers need access to reproductive health services beyond condom provision and protection against violence. These include access to effective contraception, including long acting methods, and maternity and gynaecology services. Sex workers´ intentions toward motherhood are similar to those of women in other professions, but these are often overlooked or disrespected. Many of these women would benefit from targeted pre-conception counselling (2).

In regions that enact policies that actively target sex workers for arrest and criminal charges, this fosters an attitude of fear and distrust of all authorities including the health sector, preventing them from disclosing their occupation and limiting access to appropriate care and prevention.

As with many aspects of modern medicine, the ‘problem’ that exists is not one created by health, nor can it be fixed by health – the right policy and politics need to be in place to stop criminalizing and stigmatizing sex workers before the health sector can be more effective. Similarly, with the increase in numbers of people engaging in sex work following the economic downturn in recent years, robust economic policy, stable employment and social security would be the most important intervention in the health of sex workers and the population in general.

It is always possible to find sex workers who have similar stories to Harriet and feel that they have been forced to work because of personal circumstances, and have as a consequence experienced psychological harm. However, this is not the dominant story. I have spoken to hundreds of sex workers over my career in researching sex work which has spanned over twenty years. Most of the stories I have heard are contrary to this – they are strong women who talk of numerous other choices they could have made but chose sex work because it suited their needs. They enjoy their work and only want their human rights to be respected and have the same access to justice as any other citizen.

Street-based sex workers are more vulnerable, they are a different demographic to those working in indoor settings and do experience more adverse events in their work. However, it must be remembered that they constitute only about 10% of the sex worker population [1-3]. Yet much research done to support the push for the Nordic Model is carried out with street-based sex workers and only the stories from sex workers who provide the most traumatic accounts are published, conflating all sex workers’ experiences as harrowing and damaging. Indeed, Harrington [4] has argued that experts who support the Nordic model “do encounter women who say they want to remain in the sex industry but feel no responsibility to incorporate such women’s perspectives into their research findings” (p347). Weitzer [3] termed this a ‘moral crusade’ and that many of the studies done are analytically and methodologically flawed.

There is no evidence to back up claims that the numbers of sex workers have decreased in Sweden as a result of their prostitution laws, but there is evidence to show the harms that have been caused as a result of the criminalisation of clients [5, 6]. Both the United Nations and the World Health Organisation support the decriminalisation of sex work to ensure sex workers’ human rights. What Evans et al. failed to illuminate when citing the review of the Prostitution Reform Act (PRA) which decriminalised sex work in New Zealand was the review committee’s conclusion: “On the whole the PRA has been effective in achieving its purpose, and the Committee is confident that vast majority of people involved in the sex industry are better off under the PRA than they were previously” [7].

While there is agreement that criminalising sellers of sex is counterproductive, the very different rationales and underlying philosophical positions behind the two main opposing models for reducing sexual violence to the women and girls was not fully explored. The evidence supporting the Nordic Model was not provided, while full decriminalisation was uncritically proclaimed as the answer.(1)

Our experiences of being or working with vulnerable individuals, is that distress, trauma, substance misuse, poverty or coercion can lead to prostitution; and that it causes further emotional and physical harm.(2)

Harriet – “My life is a catalogue of shame. I was sexually abused as a child, have chronic mental illness with the associated stigma as a result, and have been homeless. And now I have worked in the sex trade. Each layer of shame has more deeply stamped into me a sense of worthlessness. I was never forced into the sex trade - not by a pimp or a gang. I was forced into the trade by my ill health, a broken benefits system, and threats of imminent eviction. Under full decriminalisation, this would be legal.”

The Nordic model is part of a wider socially progressive movement to reduce violence to women, children and vulnerable individuals. It sees prostitution as harmful to most women engaged in it, and requires men to stop seeing sex as something that can be bought. As with progress in understanding and addressing domestic violence, with which it can be intertwined, it takes a public health viewpoint and puts in place legislation and social programmes to generate a shift in culture and protect the most vulnerable, even if this means some women are denied the opportunity to sell sex.

In contrast decriminalisation promotes and normalises prostitution as ‘work’ which can be sanitized and made safe. However, rather than elevate safety, full decriminalization not only blurs the boundaries of consent and makes assumptions of choice but signals state support of the objectification and victimization of the most vulnerable women and girls:

Harriet – “Abel’s commentary(3) boasts that full decriminalisation means that sex workers feel more able to contact the police when a rape or assault occurs. This does not sound like a safe job. I certainly didn’t feel safe. I knew that any one of the men could have murdered me or beaten me up, and that I couldn’t fight back when the clients raped me. Decriminalisation does not stop these rapes. Full decriminalisation colludes with the notion that a woman’s consent is negotiable; it can be bought; it can be ignored.”

The Swedish experience of the Nordic Model, following legislation in 1999 (sex buyers law), provides a case study to show the incremental hard won public health and social benefits: lower levels of street prostitution, public support, no evidence of harm increase.(4) And there are changes in the culture of men - the police, initially reluctant, now campaign actively internationally to support the law; and demand from men dropped (a reduction from 13.6% to 7.8% reporting visiting prostitutes).(4)

Claims for long term health benefits of the New Zealand model of full decriminalisation are not based on measured benefits in health. The five year review of New Zealand’s policy to bring prostitution under the Health and Safety Employment Act concluded that compliance ‘cannot be measured as there is no system of regular inspection of brothels’ and that anyway as the vast majority of prostitutes are self employed they are responsible themselves.(5)

The article also suggested that health workers generally support decriminalization. This is not the case. The passing of a supportive motion by the BMA junior doctors meeting was in fact then followed by a resounding rejection at the national BMA Area Representatives Meeting in 2017. So please let’s not talk about consensus when it does not exist. While we support the Nordic Model based on lived experience and the evidence we have, we think it vital that research is carried out as objectively as possible. Bristol University are showing the way.(6)

Social inequality is structural, an individual born and raised in a disadvantaged setting has a very low probability of having a graduate diploma or a high socio-economic status,[1] he or she would also have a very low probability of having a choice between multiple fulfilling jobs, but would have a higher probability of smoking, poor perceived health, bad diet, and cancer.[2–4]

In social epidemiology we are quick to point out to structural reasons that influence behaviors: no individual is an island, we are all affected by the structure of the society we live in. And like other health behavior, the act of buying sexual “consent”, should also be examined in light of the society where it exists.

Sex work is at the intersection of many structural inequalities and oppressions: classism, patriarchy, and in many cases racism. In fact, most sex work clients are men, most sex workers are women from socially disadvantaged settings, with few qualification and fewer choices. In a world where true sex equality is achieved, would we have significantly less acts of buying sexual “consent” and less violence against women? I would like to think so, but it seems plausible that we will never really find out. However that does not mean that we can study or theorize about sex work without at least talking about patriarchy and the sexist system we still live in, as much as we cannot study obesity without examining the influence of social inequality even if we are not even close to closing that gap either.

Sex work in a patriarchal society is inherently violent, and is linked with long term psychological consequences, substance use and higher mortality.[5] There’s no real evidence that legalization or decriminalization have resulted in a better health of sex workers. In countries where sex work has been either legalized or decriminalize sex workers still have a higher mortality rates as well as high substance and addiction problems.

I understand the benefit of risk reduction strategies in public health,[6] and the need to act based on evidence and not principles, but unlike decriminalizing cannabis use that could have benefit on health outcomes, could we really legalize and regulate violent acts on women in the name of improving access to health care, especially in capitalist societies where working is inherently exploitative? Could we live in a society that tries to denounce systematic violence against women (#MeToo), and the non-respect of consent, but also think it is normal to objectify and buy access to her body?

Short of dismantling sexism and classism, any legal framework of sex work should try first and foremost to protect the sex workers. This is why the Nordic model, that criminalizes the client, but also tries to protect the sex worker, is in my opinion the best legal framework that will optimize the health outcomes of sex workers without compromising principles.